Hip pathology quiz

You are treating a 14 year old boy who plays 3 sports. On examination, his hip flexion moves into ER at the end when moved passively. His squat depth is limited. What is the diagnosis? What causes this? Especially in what position?

CAM FAI Femoral head has an abnormally large radius which causes abnormal contract between the femoral head and the acetabulum Hip flexion combined with IR and ADD

What 3 things does the labrum do? What is common with labral derangement? What 5 things are labral tears commonly associated with?

Enhance joint stability, decrease forces transmitted to the articular cartilage, and provides proprioceptive feedback. Clicking, catching, locking in advanced cases Capsular laxity, dysplasia of the acetabulum, chondral lesions, FAI, (tears rarely occur in isolation)

What leads to the first cause of snapping hip syndrome? Second? Third?

1. Slipping of iliopsoas tendon over osseous ridge of less troch or ant acetabulum or iliofemoral ligament riding over fem head (Internal snapping) 2. Tight IT band or glute max tendon rigging over greater troch (external snapping) 3. Acetabular labral tears or loose bodies as the result of trauma or degeneration (intra-articular snapping)

You have a pt who plays hockey professionally who watched a teammate completely rupture their adductor longus. This pt wishes to begin preventative PT to avoid having this happen to them as well. What are the 6 RF that you will tell this pt that can lead to an adductor strain?

1. Sports requiring quick acc and directional changes 2. High level of play 3. Insufficient core strength 4. Decreased ROM in hip abd 5. Weak adductors 6. Abnormal add:abd ratio (should be 80%:100%

Types of hip fractures. Treatment of types 1 and 2? Treatment of types 3 and 4? Pt's with pre-existing ____ might benefit from THA. In younger pt's, a ______ in attempt to save the _____

1=incomplete 2=complete, nondisplaced 3=complete, displaced <50% 4=complete, displaced >50% Percutaneous pinning Hemiarthroplasty secondary to disruption of femoral head blood supply (osteonecrosis & non-union) DJ, THA ORIF, femoral head

What is the interesting thing about GTPS compared to trochanteric bursitis? What is the main complaint with GTSP? How do you know it isn't bursitis? What is it generally a combo of?

Less commonly diagnosed, but actually more common Pain over GT or glute med attachment. If it is bursitis it will be swollen and painful over the BURSA only. Not at the attachment of glute med. bursitis is present only in the minority of pts. Pathology involving the glute med and glute min tendons and IT band

A pregnant woman has symptoms on the anterolateral thigh. She maintains her strength and ROM. What do you think it is? How would you determine this? What is the treatment?

Meralgia Paresthetica, or entrapment of the superficial branch of the lateral femoral cutaneous nerve which occurs where the lateral femoral cutaneous nerve exits the femoral canal in the groin or next to the ASIS Possible Tinel's over ASIS or inguinal lig, she is pregnant which is a RF (along with tight clothes, heavy tool belt, obesity, and direct trauma. Rest, time, U/S, NSAIDs, corticosteroids, surgery to release the nerve in severe cases

A pt reports that he has pain in the buttock, post thigh, and calf. He has pain with walking, going up stairs, and rotating his trunk. What do you think the diganosis is and what causes it? How can you confirm it? What is the treatment for it? What does recent research say about treating it?

Piriformis syndrome which is caused by inflammation or spasm of the piriformis. Screen the hip joint and for a lumbosacral pathology Manual therapy, modalities, stretching, correction of leg length discrepancies, NSAIDs, botulinum toxin A Piriformis may be effected by weak hips. Elongated and subjected to high eccentric loads during functional movements because of weak glute max and glute med causing the hip to excessively add and IR. This adds greater ecc load to piriformis. Perpetual loading may result in sciatic nerve compression/irritation. Need to fix imbalance between internal and external rotators.

A collegiate hurdler comes to you with a hamstring strain. Where is the strain most likely located? What position and MOI most likely lead to it? At what two points in the race did most likely occur? What grade of strain is it most likely? What treatment will you give?

Probably proximal (could be mid-substance or distal) Combined max hip flex with full knee ext. rapid, uncontrolled stretchy/forceful contraction Late or early in the event Grade 1 or 2. A grade 3 is rare. An avulsion fx of the ischial tuberosity would be more common. Muscle balance, dynamics stretching. Educate pt on warm-up, stretching, training. ECC work is important! Progressive agility and trunk stabilization. Quad:Hammie ratio should be 100:60/80

What increases pain with FAI? Athletes are often able to continue but note what? What do you target for non-op treatment?

Prolonged sitting, getting in and out of a car, and heavy work Increased pain with running, jumping, and quick starts and stops. Strengthen glutes and abd, improve motion in directions other than the impairment. Increase motions at the pelvis so ROM can come from lumbar spine and pelvis instead of hips

A soccer player has strained her quadricep. What was she most likely doing when it occurred? What m is most likely involved? What might be contributing factors? What other sports is this common in?

Rapid deceleration Rectus femoris but VL and VMO may be involved Tight quads, muscle imbalance between R and L, leg length discrepancy, inadequate warm-up Sprinting, weight lifting, football, rugby

Obturator Nerve entrapment is _____ and usually associated with ______. What can occur? What might the pt report?

Rare, acute trauma such as childbirth, pelvic trauma, or surgery Adductor m might be weakened, sensation may or may not be decreased in middle portion of medial thigh Pt may report pain in inguinal ligament region, instability of the LE during gait, and atrophy of add m's.

A 32 year old marathon runner reports pain over the lateral hip and pain when going up the stairs at her home. What else might recreate her pain? What is the diagnoses and what's the interesting thing about it? What other populations might this be common in and why? What type of running form does this individual most likely demonstrate?

Sidelying w/ knees adducted, stretching glute max with full hip flex, add, and IR, and palpation over the post aspect of GT Trochanteric bursitis, which is commonly diagnosed but rarely correct Middle aged to elderly pts. Women at greater risk d/t wider pelvis Increased adduction (feet cross midline) wide pelvis, genu valgum

A pt who is 25 years old complains that they have sharp pain in ant thigh and groin, especially when pivoting. When you passively move their hip, clicking is felt/heard. What do you suspect? Why? What movements would provoke the clicking?

Snapping hip syndrome with intra-articular snapping. Pt's between 20 to 40, sharp pain in ant thighs/groin esp w/ pivoting, passively clicking is felt or heard Extended hip is adducted and EXT rotated.

What is the IHOT-33 a reliable and valid pt reported outcome questionnaire for? What is it's MIC?

Young, physically active individuals with symptomatic hip joint pathology used in research and clinical settings. 10.7 points

You are treating a pt with a grade 2 groin strain. What m is most likely affected? What are the signs of a grade 2 strain? What will you screen and what should you find? What is EBP for this diagnosis? Why is it important for conservative PT to succeed?

Adductor longus Partial disruption of fibers, significant pain, some loss of strength and ROM Screen the hip joint b/c it is a common referral site for intracapsular pathology/iliopsoas tendinitis. Symptoms should be + at the origin and with resisted add but - with the hip screen Passive PT (stretching, STM, modalities are INEFFECTIVE!) do ACTIVE PT. 8-12 weeks of strengthening for chronic groin strains. Ecc resistive ex, balance, core strengthening, sports specific activities. Correct add:abd ratio to avoid reinjury (esp hockey) Failure of conservative PT after 6 months might require an adductor tenotomy, after which only 10% will return to previous level of competition.

Where can the femoral nerve be entrapped? How does this occur?

Anywhere along its course Tumors, poses abscesses, lymph node enlargement, hematoma, penetrating trauma At the inguinal ligament or stretched when subjected to excessive hip abd and ext rotation (vaginal deliveries)

Where is the superior gluteal nerve generally entrapped? What is the cause? What are symptoms?

Between the greater sciatic notch and piriformis. Decreased hip IR, anterior rotated innominate Gluteal pain, TTP lateral to greater sciatic notch

What occurs with a pincer impingement? What can this lead to? What population is this common in, but what does continued research suggest?

Bony overgrowth of the acetabulum forces the femoral head more posteriorly onto the acetabulum Posteroinferior chondral lesions Middle aged athletic females, but both pincer and CAM will likely be seen together in symptomatic individuals

An overweight, self proclaimed couch potato, 23 year old college student reports to the clinic with pain that increases when sitting. The pain sometime refers to the post thigh. Palpation of the ischial tube is painful. What might you find in a gait observation and what stretch might produce pain? What is the diagnosis? What should you recommend the pt do? What other diagnoses do you need to rule out? What else could cause this aside from a sedentary lifestyle?

Gait: decreased hip ext in late stance, shortened stride on affected side Hamstring stretch=pain Ischial tuberosity bursitis Avoid sitting or sit on cushioned surface, NSAIDs, rest Proximal hamstring tendinopathy (bent knee stretch test) neuro screen through a slump test Trauma

A runner has pain just proximal to the greater trochanter. What do you suspect? What might have been casual factors leading to this pathology?

Glue Med strain Leg length discrepancies might increase risk, faulty motion of pelvis during running.

A Pt reports they have "completely torn" their Hamstring during a hurdle race. You perform MMT's bilaterally and score them at 3/5 on the affected leg and 5/5 on the non-affected leg. What grade of muscle strain would you assign them and what would you tell them? What else might be absent that would indicate a complete tear? What indicates that it is a more severe tear than a grade 1? What are the causes of muscle strains?

Grade 2-some disruption of the fibers, significant pain, strength and ROM decreased I would explain to them that since they do have some strength left in the muscle, it is not completely ruptured. If they had a completely torn hamstring they would have complete loss of strength. If it was completely torn, they might have bruising and ecchymosis as well as a palpable/visible defect If it was grade one, no loss of strength would be noted with an MMT. They would experience pain and a low grade inflammatory response. Minimal tissue disruption. Repetitive microtrauma or macrotrauma

You have a pt who is a collegiate sprinter with repetitive strains of the proximal hamstrings. What are you concerned might occur? How would you know if they had this? What is the las resort if conservative treatment fails? What other athletic populations is this common in?

Hamstring syndrome=entrapment of sciatic in proximal hamstring secondary to adhesions They would have a + slump or SLR w/ DF. It would worsen with sitting/stretching Surgical release

CPG for nonarthritic hip join pain 2014: 3 hip outcome measures? What should the examination of physical impairment measures include? What should treatment include

Hip Outcome Score (HOS) Copenhagen Hip and Groin Outcome score (HAGOS) International Hip Outcome Tool (iHOT33) Objective and reproducible measures of hip pain, mobility, muscle power, movement coordination. Pt education, manual therapy (joint mobs, soft tissue), ther ex, neuro re—education to diminish movment coordination impairments

An 80 year old woman with a history of OA reports her L hip hurts with pain that travels down her ant upper thigh and mid thigh. She does not remember a specific event that caused the pain, she just felt as though it came on slowly with time. Her ant hip is tender to palpation and when asked to flex the hip she reports it is too painful to do the movement. When taken into hip flex/add and ext passively she reports pain. What pathology do you suspect and why? What do you need to rule out?

Iliopectineal/iliopsoas Bursa. Pain in L2/L3 distribution (she might also report lower abdominal pain if questioned) TTP, pain generated weakness into hip flex, passive hip flex/add and passive ext painful. Rule out a joint issue by checking for capsular pattern or restriction

What treatment would you give to the 32 year old marathon runner with trochanteric bursitis?

Initially: rest, ice, NSAIDS, local corticosteroid injection U/S to increase local circulation Stretching of IT/TFL, strengthening to correct m imbalances Don't lay on affected side, pillow btwn knees Cold packs/ice massage to help reduce ex-induced inflammation

You suspect a pt has snapping hip syndrome that is either internal or external. How Will you determine which it is?

Internal will occur at 45 degrees of flexion when the hip is moving from flexion to ext, esp with hip ABD and EXT rotated. Accompanied by a pain or a jerk and palpated ant in inguinal region External will be felt more laterally than internal. It will occur during hip flex and ext, esp if the hip is held in INT rotation. May be worse if trochanteric bursa is inflamed.

How do you differentiate between intra and extra articular pathology? How long is rehab after surgical repair or debridement? What is a newer surgery? What do you address in conservative treatment?

Intra-articular injections 12 weeks Reconstruction of labrum using IT band autograft Address limitations with boney block or capsular laxity. Increase strength and proprioception